MEDICARE: JESSE E PHILLIPS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	01040385A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00000209641	OTHER	IN	ANTHEM BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457351983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE E PHILLIPS MD

Provider Business Mailing Address
First Line	:	4632 S 25TH ST
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34981-5057
Country	:	US
Telephone Number	:	772-464-9595
Fax Number	:	772-460-2624

Provider Business Practice Location Address
First Line	:	4632 S 25TH ST
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34981-5057
Country	:	US
Telephone Number	:	772-464-9595
Fax Number	:	772-460-2624

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2005
Last Update Date	:	12/09/2024

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Directions to “ JESSE E PHILLIPS MD” Practice Location

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